Laurent Koscielny’s achilles rupture: His greatest challenge yet

Twelve minutes into the 2nd leg of Arsenal’s semi-final Europa League game against Atletico Madrid (an eventual 1-0 loss, and 2-1 aggregate defeat), Laurent Koscielny suffered an achilles rupture.

Through my unique lens as a Doctor of Physical Therapy (DPT) and avid footy fan, I explore Laurent’s achilles rupture, recovery, and rehab by answering the following questions:

  • What is the anatomy and general function of the Achilles tendon?
  • Which specific football (soccer) movements stress the achilles?
  • Are there different kinds of achilles rupture?
  • What led to Laurent’s achilles rupture?
  • What are the symptoms of an achilles rupture?
  • What’s the recovery and timetable for Laurent?
  • What does the achilles rupture mean for his career?

To start, here’s a video of the injury  (I couldn’t find any better quality videos that actually showed the injury – the rest start after he’s already down on the pitch):

It’s a flat-out devastating injury. If you’re a Gooner like myself, then it’s especially difficult seeing an Arsenal stalwart like Koscielny going down.  However, based on his injury history, I can’t say that I was surprised.

I. The anatomy & function of the achilles tendon

A. The anatomy

The achilles tendon is the largest tendon in the body.  Reach down to your heel, trace upwards, and you should feel a prominent cord-like structure.  That’s your achilles tendon.

It’s the confluence point of 4 different muscles (the medical and lateral gastrocnemius, the soleus, and plantaris – these all make up your calves) and attaches onto your calcaneus (heel bone).  Here’s a visual:

achilles rupture
Credit – ResearchGate

B. The function

General

The achilles tendon has two primary general functions:

  1. It actively plantar-flexes your foot/ankle. For example, pointing your foot downwards or coming up onto your toes.  A visual:

    achilles rupture
    Credit – St Louis Health and Wellness
  2. It eccentrically controls (“brakes”) your heel coming to the ground.  For example, if you’re a midfoot runner or you land from a jump on your forefoot, the achilles lengthens to control the heel coming down to the ground.  Another visual:

    achilles rupture
    Original credit – eorthopod

Additionally, the unique elastic properties of the achilles tendon create a “passive recoil” effect.  The achilles can condense, store energy, and then expand – like a loaded spring.

In football (soccer)

The achilles tendon is constantly loaded during a football match.  Running, accelerating, jumping, landing each put varying loads onto the achilles. For a reference point, sprinting can load the achilles with up to 12x your body weight.

For Koscielny, a centreback, who has to accelerate and decelerate to close down space, keep up with speedier forwards and wingers, defend the box aerially, sprint to make up for another basic mistake by Mustafi, scramble to cut out an attacking alley after a midfield giveaway with everyone else pushed up the field…the load on the achilles may be higher than the average player.

That constant wear and tear may be part of the reason why Laurent has been dealing with achilles problems for years.  Let’s start with a look at the different types of achilles rupture.

II. Different grades of Achilles Rupture

There are 4 general categories of achilles rupture:

  • Type I: partial rupture with less than 50% of the fibers torn.  Think of this like a rope that has partially frayed.
  • Type II: complete rupture with a gap ≤3 cm. This  rope is completely torn but the ends aren’t that far apart.
  • Type III: complete rupture with a gap of 3 to 6 cm.  This rope is completely torn and the ends are pretty far apart.  This often requires surgery using a tendon graft (taking a tendon from a different part of your body or cadaver)
  • Type IV: complete rupture with a gap of >6 cm.  This rope is fully torn and the ends are very apart, often because the injury was neglected and did not receive appropriate medical attention.  This almost always requires surgery.

I haven’t been able to find any specific information on whether Laurent had a type II or III rupture but I have some ideas as to what caused it.

III. What caused Laurent’s achilles rupture?

Previous achilles problems are a major risk factor for further injury or rupture. Nearly 10% of people with an achilles rupture have previous achilles issues.  Koscielny definitely falls into that category:

Back in May of 2017, Laurent commented on his daily battle with his achilles:

“I have some problems. Now it is better. I know it is a difficult injury because you need to work every day on this.

 

“Every morning I have my treatment for my Achilles and I know I need to do this to the end of my career. Sometimes with all the games we play every three days, it is difficult and I need to have a rest to recover well.

 

“You need to be careful with this because if you stop doing your own exercise program for one or two weeks, the problem will come back.”

Clearly Laurent’s achilles problems are a chronic issue.  Chronic achilles tendopathy results in disorganized tissue that weakens the tendon and makes it more susceptible to tearing, partially or fully.

Additionally, Koscielny has dealt with many other injuries:  back injuries twice, knee injuries twice, thigh injuries twice, and calf problems on 4 different occasions (and these are just the reported ones).  Each and all of these can lead to compensatory movement patterns and changes in loading throughout the lower body, creating more injury risk.

When you combine these compensations with a weakened achilles tendon that is constantly put through high load movements, it raises the risk for an achilles tear. In Laurent’s case, it was a high load plantar-flexion force (accelerating and pushing off with his forefoot) that caused the achilles rupture.

First, check out this anatomical representation:

achilles rupture
Original Credit – achillestendonfacts

And now here’s a frame by frame breakdown of the sequence leading to Koscielny’s achilles rupture (again, my apologies for the blurriness):

achilles rupture
credit – BPL

Laurent attempts to close down Costa on his left and pushes-off with his right foot.  That push-off requires the foot to plantar flex and puts a significant load on the achilles tendon. That’s the moment it ruptures.

achilles rupture
Credit – BPL

Following the achilles tendon rupture, Laurent’s lower leg collapses.  I won’t re-live the following moments with pictures but Koscielny goes down to the pitch in agony.  In a surprise turn of events, it’s actually Costa who signals to Atletico to stop their attack and bring on the medical team. Kudos when they are due.

Additionally, over 80% of achilles ruptures occur during a sport activity, most commonly in males between 30 to 49 years old. Koscielny is 32 and closing in on 33 (September).

III. The symptoms of an achilles rupture

An achilles rupture is characterized by the following symptoms:

  • You may feel or hear a “pop” or feel like someone kicked you in the back of the leg
  • Pain with walking or an inability to walk
  • A gap or indentation in the achilles tendon. It looks like this:

    achilles rupture
    Credit – AMC academic systems
  • Significant weakness or inability to plantar-flex (point your foot downwards)
  • Squeezing the calf doesn’t result in plantar-flexion.  This is known as the Thompson test.  Go to the :40 mark of the following video:

These are all indicators of an achilles rupture.  An MRI is the gold standard for confirming or denying the extent of the tear. An MRI confirmed Koscielny’s achilles rupture.

IV. Achilles rupture protocol

There’s still debate as to whether a non-operative (conservative) or operative (surgical) approach is optimal following an achilles rupture.

For most people, the conservative route results in similar outcomes to the surgical route.  The risk for re-rupture is slightly higher in the former but there’s also less chance of infection.

However, surgery does result in significantly better function during high load high-speed activities like sprinting and jumping.  Therefore, for athletes, surgery is highly recommended.

Koscielny did have surgery and according to him, it went well.

There are multiple types of achilles surgery but the goal is the same: re-connect the tendon and make sure the tension level is similar to where it was pre-injury.

Here’s one example of what surgery may look like (work-safe):

achilles rupture
Credit – South Florida School of Medicine

Now that Laurent achilles rupture repair is complete, he moves onto rehab and recovery…

V. Koscielny’s rehab and return to play timeline

Overall, research has shown that the average return to play timeline after achilles rupture is roughly 6 months.  To organize the multiple layers of Laurent’s rehab and recovery, I’ve divided this section into a holistic micro (tissue), mezzo (systemic), and macro (contextual) model.

A. Micro (tissue)

The paradigm of Achilles rupture rehab after surgery is shifting towards earlier and earlier weight-bearing.  More and more evidence is showing that earlier weight-bearing results in improved tendon healing with no increase in the risk for re-rupture.

Multiple rehab protocols exist and the general theme is similar (keep in mind, these are rough timeframes that can certainly vary):

  • From post-op to 3 weeks
    • Control swelling and protect the incision site
    • Minimize scar adhesions
    • Progress weight-bearing as tolerated
    • Increase range of motion
    • Gain near normal strength in all lower body muscles except the plantar-flexors
    • Pain at or less than 5/10
  • From 3 weeks to 6 weeks
    • Full ankle range of motion
    • Full strength in lower body
    • Able to complete normal activities of daily living (ADLs)
    • Less than 2/10 pain reported
  • 6 weeks to 15+ weeks
    • Progressive loading and strengthening
    • Increased intensity of activity (like starting to run)
    • Adding variety of activity (like introducing agility training)

B. Mezzo (systemic)

There are numerous systems which can affect recovery and unlock significant gains. Humans are an ecosystem so nothing can be considered in isolation.

  • Bio-mechanics and movement patterns
    • Re-training and establishing normal walking as quickly as possible is critical. This is a primary focus in the first 3 weeks of rehab.
    • As Laurent returns to full training, addressing any movement patterns which may increase stress on the achilles, such as:
      • Over-striding aka reduced knee flexion (bending) during walking and running. This picture is a good visual of over-striding:

        achilles rupture
        Credit – Fellrnr
      • Increased duration of pronation (the foot and arch going flat). Pronation itself isn’t an issue (very common misconception), rather it’s how long the foot is pronated for. This is commonly due to poor foot/ankle muscle strength and therefore poor control of pronation.
      • Here’s a video of pronation and supination (the arch going up):

  • Sensory systems, specifically his proprioceptive and vestibular systems
    • These systems are responsible for providing feedback to Laurent’s brain about where his body is in space. Based on this feedback, the brain makes little adjustments and activates certain muscles to make movement more efficient, effective, and safe.
    • The proprioceptive system can directly be affected by injury as it uses receptors near the muscles for feedback.  These can be impaired by swelling.
    • Proprioception and vestibular training will begin within the first 3 weeks after surgery and be incrementally progressed
  • Neuro-muscular
    • A delayed onset or shortened duration of muscle activation has been linked to increased strain on the achilles, specifically of the:
      • Anterior tibialis (a muscle on the front of the shin)
      • Gluteus medius (major hip muscle which controls hip abduction aka your leg moving away from midline)
      • Gluteus maximus (another major hip muscle)
  • Central nervous system (CNS)
    • The CNS is comprised of two systems:  the sympathetic nervous system (SNS) which creates the stress or “fight or flight” response, and the parasympathetic nervous system (PSNS) which creates the relaxation or “rest and digest” response.
    • A ramped up SNS makes healing and injury rehab more difficult by affecting you cognitively, physically, and emotionally.
      • Cognitively:  The brain’s main role is to anticipate and prepare for threat.  When you’re stressed, the brain is on high alert which creates a heightened sense of threat and fixation on problems.  In turn, the brain sends out more pain signals (aka MORE PAIN) to alert the body
      • Physically: Stress results in a multitude of physical changes including increased systemic inflammation, increased muscle tension, deregulated immune response, etc.  Each of these negatively impacts healing.
      • Emotional/Behavior: Stress can alter major health drivers like sleep, nutrition (“binge-eating” for example), and exercise patterns.  Changes in these key areas exacerbates all other existing issues.
    • Chronic pain
      • Koscielny’s achilles issue is long-standing and chronic. This can affect his pain perception and sensitivity to it.
      • The brain has one goal – protect its vessel (the body) and it’s constantly assessing how dangerous something is. If it perceives a threat, it sends a pain signal to alert the body to danger. Here’s an overview:

        achilles rupture
        credit – body in mind
      • This response can be very beneficial (adaptive) in the short-term, but with chronic lingering injuries it can become detrimental (maladaptive) – continuing to send pain signals even after the tissue or bone itself has healed. This is why tissue and bone healing alone aren’t indicators that a player is ready to return to play.
      • Chronic pain responses can lead to increased sensitivity of pain. There’s a saying “neurons that fire together, wire together”. Essentially, when groups of neurons fire together (like during a specific movement), they become more efficient and the threshold to activate them decreases.
      • This is great for certain things like increasing the efficiency of a movement or recognizing patterns. However, when applied to pain, constant activation of the same pain circuit (like pain with certain movements or pain in certain body regions) leads to decreased stimulus required and more efficient firing of pain circuits. This means increased sensitivity to pain & increased pain response
      • Another aspect of pain sensitivity is termed “neuro-tagging”. The brain creates memories of experiences (called neurotags or neurosignatures) to organize them efficiently. Each memory creates a certain output. For example, when you hear a certain song or smell a certain scent, it may instantly harken you back to a memory or experience. That’s due to a neurotag.
      • The same exact thing applies to pain. A certain movement or context elicits a pain response and over time, that movement is neuro-tagged as being painful – in other words, you’re conditioned to feel pain with that movement.
      • Lastly, there’s an aspect of pain science that I call “fixation”. When you have chronic pain, you tend to focus more and more on the body part and become increasingly aware of it. There are specific parts of the brain which are “mapped” to specific body parts, this is called the homunculus (*cue Fullmetal Alchemist flashbacks*):

        achilles rupture
        Credit – NeuroWiki
      • Studies have shown that chronic pain actually increases the mapped area in the brain responsible for that body part (this is called cortical re-organization). This creates increased awareness and feedback of that area (like “shining a spotlight on it”) which leads to more pain.
    • For these reasons, it’s critical to keep Laurent in a relatively stress-free and balanced state from day 1 through full recovery to maximize his healing environment.

C. Macro (contextual) factors

There are many contextual factors that could play a part in how Koscileny responds to rehab and how quickly he returns to play.

1 – Team and family support

Rehab can be a very lonely place, especially for a professional athlete who is spending hours upon hours with the same person, away from the team.  Staying connected and being surrounded by team and family support can be key for keeping spirits up and maintaining motivation.

I expect Laurent to have great support from his team and teammates as he’s been with Arsenal for 8 years and is tight with the players.  Additionally, he’s been a mainstay on the France international team.

Here’s what he had to say about the club and his family life:

When I first got here, I didn’t think about how long I would stay at this club – but now I am starting my eighth season so I am very happy with this. I am happy in my life every day, not just the football but my life with my wife and kids in London. We enjoy it, that’s why I have stayed for a long time here.

Further, in just a few days there’s already been great support from his family, manager, teammates and fans.

Here he is with his family after the surgery:

Arsene Wenger commenting:

“We always try to be positive and you can only try to support people when they suffer”

An outpouring of support from the fans, to which Laurent responded:

“I wanted to thank you for the many messages received since my injury”

 

2 – Missing the World Cup

I can’t imagine how frustrating and saddening it is for Koscielny to miss the World Cup due to injury – let alone to get injured months before what was supposed to be his final World Cup.  That kind of frustration, depression, anger – if left unchecked – can snowball and affect all other aspects of life.

Here’s what France head coach Didier Deschamps had to say on it:

“I am really very sad for him because this World Cup was also a very important moment for him in his career.”

3 – Wenger leaving

achilles rupture
Credit – Evening Standard

Any Arsenal fan knows just how loyal Arsene is to his players (Mikel Arteta comes to mind) and if he was still manager, I have no doubt Koscielny would be given a completely fair shot to earn his spot back.

However with a new manager who doesn’t have the loyalty to Koscielny and frankly will be under a lot of pressure with large loafers to fill, is that same opportunity, patience, and confidence afforded to Laurent?

Don’t know.

However, there is a key silver lining here – as a long-time Arsenal player and club loyalist, I’m inclined to believe that Laurent doesn’t want to leave during a state of transition but rather wants to help lead them through it.  This can be huge for his motivation level.

4 – Resiliency

I wanted to put this one last so it really stays in your head when thinking about Koscielny’s return.  I can’t emphasize enough the importance of mental resiliency and perspective when recovering from an injury.

The mindset of viewing an injury as a depressing obstacle vs viewing it as a new challenge can completely shift recovery, commitment, and motivation.  I’m extremely happy that Laurent has shown the latter in days after his surgery, exemplified by this quote on IG following surgery:

I would like to thank you for all the messages received further to my injury. The operation went well, it’s a new step that begins for me … I’m determined to fight not only for myself but also for my family, my friends and all the people who support me … See you soon lolo

This is a key indicator of his mental state and how he’s cognitively framing the mental and physical grind of getting back on the pitch.

VI. Long-term implications

There are considerable long-term implications for Koscielny after the achilles rupture.

Many studies have followed individuals after achilles rupture and the results don’t paint a rosy picture.  Long-term changes in muscle strength, endurance, muscle activity, ankle range of motion, and calf atrophy – for up to 10 years after the rupture.  In the case of athletes involved in running, bio-mechanical and muscle deficits can persist for up to 4 years after the injury.

Further, for those athletes who do return from achilles rupture, recent research has shed a light on performance effects.

Of athletes who were able to play at least 2 seasons after returning from the achilles rupture (nearly 57% weren’t able to meet this criteria for a variety of reasons), they participated in significantly fewer games and had significant decreases in secondary measures of longevity and performance metrics after year 1.

HOWEVER, those athletes who were able to play 2 or more years were able to perform at a level commensurate with their non-injured counterparts.

Lastly, there’s a small chance for re-rupturing the achilles tendon.  Studies have shown about a 4% chance of achilles re-rupture using the early weight-bearing rehab protocol.

So here’s the reality for Koscielny after suffering an achilles rupture:  Odds are that he will play 1 year or less after this injury, but if he’s able to play 2 years,  he could return to being a higher tier centreback.

VII. All in all

Overall, an achilles rupture is a brutal injury – regardless of when it happens or who suffers it.

For Laurent, it could be especially devastating because he’s in the final arch of his career, the team is transitioning to a new era, and many athletes aren’t able to return for more than a year, if at all.

That being said, Koscielny has key positive attributes around him that bode well for his return. He has has full access to a medical staff 24/7, has a very supportive and positive environment around him with the team, family, and fans, and he’s already shown a mental resiliency and motivation to return.

Time will tell but I’ll always give Koscielny the benefit of the doubt when it comes to returning from a setback, even one as brutal as an achilles rupture.  At the least, I know he’ll give his all in trying to get back on the pitch and compete at a high level for Arsenal yet again.

After all:

Ain’t nobody,

like Koscielny,

makes me happy,

makes me feel this way.

Thanks for reading, until next time.

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